1. Field of the Invention
This invention relates to computerized practice management systems for doctors' offices and other medical service providers in providing services to their patients, and is particularly related to the use of these systems for tracking the medical care being provided to the patients and reporting quality of care results to the patients' insurance providers.
2. Related Art
The 2004 Current Procedural Terminology (CPT) book produced by the American Medical Association included a new category of CPT codes, Category II Codes. These codes were intended to facilitate data collection about the quality of care rendered by coding certain services and test results that support nationally established performance measures and have an evidence base as contributing to quality of patient care. These codes describe clinical components that may be included in evaluation and management services or other clinical services and therefore do not have a direct monetary values associated with them. Category II codes may also describe laboratory test results, medicines being prescribed and procedures intended to address patient safety practices, or services reflecting compliance with state or federal law. The AMA has updated, added to and amended this code set biannually since 2004. It would be expected that the number of codes and services described will continue to increase in the foreseeable future. CPT is a registered mark of the American Medical Association, and the CPT codes are widely used in the medical field with other medical procedural codes, including quality measure codes and corresponding medical nomenclature for tracking and reporting medical procedures and services, including CPT Category I and now CPT Category III.
The Tax Relief and Health Care Act of 2006 (TRHCA) authorizes a physician quality reporting system. This performance measurement program, which the Centers for Medicare & Medicaid Services (CMS) named “Physician Quality Reporting Initiative” (PQRI), was implemented on Jul. 1, 2007. The TRHCA specifically authorized, and established provisions for implementation of, bonus payments for satisfactory submission of data on the quality of covered professional services furnished to Medicare beneficiaries.
The PQRI program is defined by a matrix of quality measures developed by CMS. In general, the quality measures consist of a numerator and a denominator that permit the calculation of the percentage of a defined patient population that receive a particular process of care or achieve a particular outcome. The denominator population is defined by certain ICD-9 and CPT Category I codes (medical condition codes generally) specified in the measure that are submitted as part of a claim for Medicare Physician Fee Schedule services by eligible professionals. The International Classification of Diseases, 9th Revision (ICD-9) is maintained jointly by the National Center for Health Statistics (NCHS) and the Centers for Medicare & Medicaid Services (CMS). If the specified denominator codes for a measure are not included in the patient's claim as submitted, then the patient does not fall into the denominator population, and the PQRI measure does not apply to the patient. For patients that are included in the denominator population, the applicable CPT Category II code (or other quality measure codes, such as the temporary HCPCS G code where CPT Category II codes are not yet available) that defines the numerator should be submitted. Where a patient falls in the denominator population but specifications define circumstances in which a patient may be excluded from the measure's denominator population, CPT Category II code modifiers 1-P, 2-P, or 3-P are available to describe medical, patient, or system reasons, respectively, for such exclusion. In situations for which exclusions do not apply, the CPT Category II modifier 8-P may be used to indicate that the process of care was not provided for a reason not otherwise specified.
To successfully report quality data for a measure under the PQRI program, a quality measure code (CPT Category II code or G code) must be reported for a numerator match with the denominator population, with or without an applicable CPT Category II code modifier (1-P, 2-P, 3-P, or 8-P). Instructions specific to each measure provide additional reporting information. Instructions for some measures limit the frequency of reporting necessary in certain circumstances, such as for patients with chronic illness for whom a particular process of care is provided only periodically. The measure specifications are organized to provide the information in a standardized format, having a Measure Title, Measure Description, Instructions on Reporting (frequency, timeframes, and applicability), Numerator Coding, Definitions of Terms, Coding Instructions, CPT Category II Exclusion Modifiers, Denominator Coding, Rationale Statement and Clinical Recommendations. Examples of quality reporting measure criteria are available through the CMS web site (www.cms.hhs.gov/apps/QMIS/browseMeasures.asp).
Providers currently have an option to participate or not participate in the PQRI program. However many people believe that at some future point CMS may make this a mandatory program. It is also quite possible that many private insurance companies may adapt the PQRI or some other pay for performance model based on the same or similar quality measures. These performance measurement programs may be either optional or mandatory.
There are several difficulties that providers and their staff face in participating in performance measurement programs. First, not all of the quality measures are appropriate for all patients. Appropriateness may be bases on any combination of diagnoses, procedures and tests performed, age and sex of patient. Also, not all of the quality measures are appropriate to all practices, and the physician and staff must decide which measures are appropriate to their practice and their patients and also choose the measures for which they expect to participate in the program. Once the decision is made on the measures for participation, the information must be communicated to all of the members in the healthcare team who are involved in providing, ordering, documenting or reporting appropriate services. Due to the large number of patients seen by providers and the number of measures which are available, keeping track of what services to provide and report can be very difficult for the providers and staff.
Additionally, Medicare's program is designed to allow the provider to participate in the program and send in the quality measure data with their claims. However, in order to receive any bonus, the provider must report on a minimal percentage of all patients that qualify for a particular quality measure which results in bonus payments being an all or nothing proposition. Therefore, if a provider or a member of the healthcare staff forgets to report the appropriate data even one time, it could mean the difference in whether the provider receives a significant payment or receives nothing.
CMS created the 2007 Physician Quality Reporting Initiative (PQRI), which establishes a financial incentive for eligible professionals to participate in a voluntary quality-reporting program. Eligible professionals who successfully report a designated set of quality measures on claims for dates of service during a set period of time may earn a bonus payment of total allowed charges for covered Medicare physician fee schedule services during that same period. CMS Specifications for reporting the quality measures are defined on the CMS PQRI website (http://www.cms.hhs.gov/pqri). In 2007, PQRI reporting was based on seventy-four (74) unique measures and continues to grow in scope.
On its web site, CMS provides a PQRI “Tool Kit” to help healthcare professionals use PQRI measurements and reporting in their respective medical practices (www.cms.hhs.gov/PQRI/31_PQRIToolkit.asp). However, the PQRI “Tool Kit” is a manual system that is not integrated into the computerized practice management systems that are used by many healthcare professionals and there is no recommendation or other suggestion on how the manual system may be automated or incorporated into computerized practice management systems. Although the PQRI Tool Kit allows providers to download files which contain work sheets to assist in (1) deciding which of the quality measures they might participate in, (2) identifying patients who meet the qualifications for reporting, and (3) assisting in the decisions of what data and level II codes to report, the lack of automation leaves the provider and staff with the additional problems of remembering the measures for which they have chosen to participate in the program, remembering the required services and making sure the necessary data is reported, and communicating all of the relevant information to the appropriate office staff for the medical practice.
Accordingly, the prior systems and resources are paper-driven, manual operations which require the provider to remember the measures, patients and requirements needed to be reported as well as ensuring that the information is reported. With hundreds of requirements that can change over time and may vary depending on combinations of diagnoses, patient age and gender, and procedures and tests performed, it is an overwhelming task to manually manage the information. Accordingly, there remains a need for assisting providers with an automated tool to manage the information and provide a knowledge-based process for managing the care of patients and the reporting of the care to the patients' insurance providers.